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Matava CT, Bordini M, Jasudavisius A, Santos C, Caldeira-Kulbakas M. Comparing the Effectiveness of a Clinical Decision Support Tool in Reducing Pediatric Opioid Dose Calculation Errors: PediPain App vs. Traditional Calculators - A Simulation-Based Randomised Controlled Study. J Med Syst 2024; 48:43. [PMID: 38630157 DOI: 10.1007/s10916-024-02060-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/03/2024] [Indexed: 04/19/2024]
Abstract
Wrong dose calculation medication errors are widespread in pediatric patients mainly due to weight-based dosing. PediPain app is a clinical decision support tool that provides weight- and age- based dosages for various analgesics. We hypothesized that the use of a clinical decision support tool, the PediPain app versus pocket calculators for calculating pain medication dosages in children reduces the incidence of wrong dosage calculations and shortens the time taken for calculations. The study was a randomised controlled trial comparing the PediPain app vs. pocket calculator for performing eight weight-based calculations for opioids and other analgesics. Participants were healthcare providers routinely administering opioids and other analgesics in their practice. The primary outcome was the incidence of wrong dose calculations. Secondary outcomes were the incidence of wrong dose calculations in simple versus complex calculations; time taken to complete calculations; the occurrence of tenfold; hundredfold errors; and wrong-key presses. A total of 140 residents, fellows and nurses were recruited between June 2018 and November 2019; 70 participants were randomized to control group (pocket calculator) and 70 to the intervention group (PediPain App). After randomization two participants assigned to PediPain group completed the simulation in the control group by mistake. Analysis was by intention-to-treat (PediPain app = 68 participants, pocket calculator = 72 participants). The overall incidence of wrong dose calculation was 178/576 (30.9%) for the control and 23/544 (4.23%) for PediPain App, P < 0·001. The risk difference was - 32.8% [-38.7%, -26.9%] for complex and - 20.5% [-26.3%, -14.8%] for simple calculations. Calculations took longer within control group (median of 69 Sects. [50, 96]) compared to PediPain app group, (median 48 Sects. [38, 63]), P < 0.001. There were no differences in other secondary outcomes. A weight-based clinical decision support tool, the PediPain app reduced the incidence of wrong doses calculation. Clinical decision support tools calculating medications may be valuable instruments for reducing medication errors, especially in the pediatric population.
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Affiliation(s)
- Clyde T Matava
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Toronto, Toronto, ON), Canada.
| | - Martina Bordini
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Toronto, Toronto, ON), Canada
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Amanda Jasudavisius
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre, Kingston, ON), Canada
| | - Carmina Santos
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Monica Caldeira-Kulbakas
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
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Patel S. Cardiovascular Drug Administration Errors During Neuraxial Anesthesia or Analgesia-A Narrative Review. J Cardiothorac Vasc Anesth 2023; 37:291-298. [PMID: 36443173 DOI: 10.1053/j.jvca.2022.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/13/2022] [Accepted: 10/19/2022] [Indexed: 11/07/2022]
Abstract
The prevalence and harm associated with inadvertent neuraxial cardiovascular (CV) medication administration errors are unknown. This review aims to analyze neuraxial CV drug administration errors and associated clinical consequences. The secondary objective is to identify the causes and contributory factors in order to prevent future incidents. The author reviewed reports of accidental administration of CV medications via neuraxial routes during spinal or epidural anesthesia or analgesia published in the last 5 decades (1972-2022). Twenty-seven publications reported neuraxial administration of 10 different CV drugs among patients aged 1 to 81. Seventeen of the 33 errors occurred via the epidural route. Digoxin (9 patients), ephedrine (6), metaraminol (4), labetalol (4), and dopamine (3) were frequently involved in the incidents. Intrathecal digoxin (8 patients) was associated with paraplegia and encephalopathy, of whom 4 pregnant women scheduled for elective cesarean delivery sustained permanent lower limb neurologic deficits. Reversible systemic hemodynamic changes were predominant following the administration of epidural inotropes (dobutamine, dopamine, and epinephrine) and vasopressors (ephedrine and metaraminol). Most administrations (30 out of 32) were only bolus injections. All were preventable skill-based errors. The human factor analysis classification system (HFACS) identified poor organizational climate, inadequate supervision of junior doctors, deficiencies in neuraxial task processes, and incorrect visual perception of objects. The HFACS suggests CV medication safety strategies should include better education and training of junior doctors, modifications in neuraxial anesthesia practices, and careful handling of the CV drug ampoules and syringes.
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Affiliation(s)
- Santosh Patel
- Department of Anaesthesia, Tawam Hospital, Al Ain, Abu Dhabi, United Arab Emirates.
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Erstad BL, Romero AV, Barletta JF. Weight and size descriptors for drug dosing: Too many options and too many errors. Am J Health Syst Pharm 2023; 80:87-91. [PMID: 36194119 DOI: 10.1093/ajhp/zxac283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Indexed: 01/19/2023] Open
Affiliation(s)
- Brian L Erstad
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA
| | | | - Jeffrey F Barletta
- Department of Pharmacy Practice, College of Pharmacy, Midwestern University, Glendale, AZ, USA
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To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. AORN J 2022; 116:485-487. [DOI: 10.1002/aorn.13796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 07/05/2022] [Indexed: 11/05/2022]
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Routman J, Boggs SD. Patient monitoring in the nonoperating room anesthesia (NORA) setting: current advances in technology. Curr Opin Anaesthesiol 2021; 34:430-436. [PMID: 34010175 DOI: 10.1097/aco.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Nonoperating room anesthesia (NORA) procedures continue to increase in type and complexity as procedural medicine makes technical advances. Patients presenting for NORA procedures are also older and sicker than ever. Commensurate with the requirements of procedural medicine, anesthetic monitoring must meet the American Society of Anesthesiologists standards for basic monitoring. RECENT FINDINGS There have been improvements in the required monitors that are used for intraoperative patient care. Some of these changes have been with new technologies and others have occurred with software refinements. In addition, specialized monitoring devises have also been introduced into NORA locations (depth of hypnosis, respiratory monitoring, point-of care ultrasound). These additions to the monitoring tools available to the anesthesiologist working in the NORA-environment push the boundaries of procedures which may be accomplished in this setting. SUMMARY NORA procedures constitute a growing percentage of total administered anesthetics. There is no difference in the monitoring standard between that of an anesthetic administered in an operating room and a NORA location. Anesthesiologists in the NORA setting must have the same compendium of monitors available as do their colleagues working in the operating suite.
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Affiliation(s)
- Justin Routman
- Department of Anesthesiology and Perioperative Medicine, The University of Alabama at Birmingham, Alabama, USA
| | - Steven Dale Boggs
- Department of Anesthesiology, College of Medicine, The University of Tennessee Health Science Center, Tennessee, USA
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Bratch R, Pandit JJ. An integrative review of method types used in the study of medication error during anaesthesia: implications for estimating incidence. Br J Anaesth 2021; 127:458-469. [PMID: 34243941 DOI: 10.1016/j.bja.2021.05.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 12/20/2022] Open
Abstract
To meet the WHO vision of reducing medication errors by 50%, it is essential to know the current error rate. We undertook an integrative review of the literature, using a systematic search strategy. We included studies that provided an estimate of error rate (i.e. both numerator and denominator data), regardless of type of study (e.g. RCT or observational study). Under each method type, we categorised the error rate by type, by classification used by the primary studies (e.g. wrong drug, wrong dose, wrong time), and then pooled numerator and denominator data across studies to obtain an aggregate error rate for each method type. We included a total of 30 studies in this review. Of these, two studies were national audit projects containing relevant data, and for 28 studies we identified five discrete method types: retrospective recall (6), self-reporting (7), observational (5), large databases (7), and observing for drug calculation errors (3). Of these 28 studies we included 22 for a numerical analysis and used six to inform a narrative review. Drug error is recalled by ~1 in 5 anaesthetists as something that happened over their career; in self-reports there is an admitted rate of ~1 in 200 anaesthetics. In observed practice, error is seen in almost every anaesthetic. In large databases, drug error constitutes ~10% of anaesthesia incidents reported. Wrong drug or dose form the most common type of error across all five study method types (especially dosing error in paediatric studies). We conclude that medication error is common in anaesthetic practice, although we were uncertain of the precise frequency or extent of harm. Studies concerning medication error are very heterogenous, and we recommend consideration of standardised reporting as in other research domains.
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Affiliation(s)
- Ravinder Bratch
- Pharmacy Department, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Jaideep J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals, Oxford, UK.
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Gonzalez LS, Chaney MA, Wahr JA, Rebello E. What's in That Syringe? J Cardiothorac Vasc Anesth 2020; 34:2524-2531. [PMID: 32507463 DOI: 10.1053/j.jvca.2020.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/04/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Laura S Gonzalez
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL.
| | - Joyce A Wahr
- Department of Anesthesiology,University of Minnesota, Minneapolis, MN
| | - Elizabeth Rebello
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
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Wanderer JP, Nathan N. Drug Calculation Errors in Anesthesia. Anesth Analg 2019; 128:1056. [DOI: 10.1213/ane.0000000000004198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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